Provider Demographics
NPI:1346647823
Name:LEIST, JENNIFER (DC)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
Last Name:LEIST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:LEIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:998 FREMONT AVE
Mailing Address - Street 2:SUITE L1
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52003-0300
Mailing Address - Country:US
Mailing Address - Phone:563-556-6921
Mailing Address - Fax:563-556-6923
Practice Address - Street 1:998 FREMONT AVE
Practice Address - Street 2:SUITE L1
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52003-0300
Practice Address - Country:US
Practice Address - Phone:563-556-6921
Practice Address - Fax:563-556-6923
Is Sole Proprietor?:No
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA076181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor